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Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods

Final Report

by Ashley M. Kranz, Teague Ruder, Ateev Mehrotra, Andrew W. Mulcahy

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Research Questions

  1. How many post-operative visits were reported following a Medicare requirement to report visits in select states?
  2. How did the volume of post-operative visits reported in Medicare claims data vary over time and across states, practice sizes, and physician specialties?
  3. What share of procedures had any post-operative visits?
  4. What was the ratio of observed to expected post-operative visits?

This report was initially published in 2019; this update was published in 2021 and includes clarification on RAND's definition of clean procedures.

Medicare payment for most surgical procedures covers both the procedure and post-operative visits occurring within a global period of either ten or 90 days following the procedure. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, Medicare required select practitioners to report on their post-operative visits beginning July 1, 2017.

Medicare fee-for-service claims data from practitioners who billed Medicare for select procedure codes between July 1, 2017, and June 30, 2018, in the nine states where practitioners were required to report post-operative visits were analyzed. To correctly link a given procedure and post-operative visit(s), analyses were limited to procedures that did not occur within the global period of another procedure with a 10- or 90-day global period.

There were 1.4 million procedures linked to 931,640 post-operative visits. The share of procedures with one or more associated post-operative visits reported was 3.7 percent for procedures with 10-day global periods and 70.9 percent for procedures with 90-day global periods. The ratios of observed to expected post-operative visits provided for procedures with 10- and 90-day global periods were 0.04 and 0.39, respectively.

The low proportion of expected post-operative visits provided suggests the need to revalue procedures with a global period.

Key Findings

The share of procedures with any post-operative visits is low

  • The vast majority of procedures with 10-day global periods did not have an associated post-operative visit.
  • Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit.

Fewer total visits were provided than what was expected

  • The ratio of observed to expected post-operative visits provided was 0.04 for procedures with 10-day global periods and 0.39 for procedures with 90-day global periods.
  • Using a more expansive definition of post-operative care did not have a substantive impact on the patterns observed.

A large share of expected post-operative visits are not observed in the data, suggesting the need to revalue procedures with a global period

Recommendations

  • To address the potential overvaluation of global surgical packages, the Centers for Medicaid and Medicare Services (CMS) could request new information from the RVS (Relative Value Scale) Update Committee on expected counts of post-operative visits. The RVS Update Committee could use the data in this report to inform those revaluations or conduct new surveys on the typical number of post-operative visits.
  • Because the share of procedures with 10-day global periods and any post-operative visits was very low, CMS should consider converting some or all 10-day global procedures to 0-day global procedures. Practitioners who furnish post-operative visits for such procedures could be paid separately by billing typical evaluation and management codes.
  • Using the information on post-operative visits provided in this report, CMS could consider revaluing all procedures with 10- and 90-day global periods using the number of post-operative visits.

Table of Contents

  • Chapter One

    Background

  • Chapter Two

    Data and Methods

  • Chapter Three

    Examining Number of Post-Operative Visits Reported

  • Chapter Four

    Examining the Share of Practitioners Engaged in Claims-Based Reporting of Post-Operative Visits

  • Chapter Five

    Timing of Post-Operative Visits and the Fraction of Expected Post-Operative Visits Reported

  • Chapter Six

    Sensitivity Analysis: Examining Procedures Performed by Practitioners Actively Reporting Post-Operative Visits

  • Chapter Seven

    Sensitivity Analysis: Using an Expanded Definition of Post-Operative Visits

  • Chapter Eight

    Conclusions

  • Appendix A

    Examining Characteristics of Clean Procedures

  • Appendix B

    Identifying Robust Reporters of Post-Operative Visits

  • Appendix C

    Observed to Expected Ratio of Post-Operative Visits for All Procedures

  • Appendix D

    Exploring Visits Immediately Following Global Periods

Research conducted by

The research described in this report was funded by the Centers for Medicare & Medicaid Services (CMS) and conducted by the Payment, Cost, and Coverage Program within RAND Health Care.

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